Iowa Form 470 0040 PDF Details

Are you looking to understand Iowa Form 470 0040? You're in the right place! This blog post provides a comprehensive introduction to this important form, as well as an outline of how it can be used by tax filers in Iowa. We'll provide clear explanations on what information is required and where to find more details if necessary. By reading through our post, you'll gain a thorough understanding of this form and its purpose so that you can confidently move forward with your filing process.

QuestionAnswer
Form NameIowa Form 470 0040
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesMoines, NPI, retracting, TCN

Form Preview Example

Adjustment Request

Return Requests to: Iowa Medicaid Enterprise PO Box 36450

Des Moines, IA 50315

Download this form @ http://www.ime.state.ia.us/Providers/Forms.html#DF

SECTION A: Reason for adjustment; please select at least one reason.

•A corrected claim and/or remittance advice (with changes, when applicable) must be attached with each request.

•Denied claims should be resubmitted

•Do not use red ink

Please select changes or corrections to be made:

 

Primary Insurance

Dates of Service

Medical Review Needed

Patient Liability

Diagnosis Code(s)

 

Medicare Adjustment (EOMB from Medicare must be attached)

Units

Line Number(s)

_______________

Billed Amount

Line Number(s) ________________

Procedure Code(s)

Line Number(s) ________________

Modifier(s)

Line Number(s) ________________

Adding New Claim Detail

Line Number(s) ________________

Please Specify the Reason for the Adjustment Request:

SECTION B: This section must be completed to process the request.

•17-Digit TCN: _________________________

•

NPI Number:

__________________

Taxonomy:

_________________ Zip: ______

•

State ID:

______________

Patient Acct #: __________

 

 

 

 

Signature:

 

 

Date:

 

 

 

 

 

470-0040 (Rev. 8/11)

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